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Case Study 64 year old male undergoing craniotomy listing Succinylcholine as an “allergy” The patient has a diagnosis of pseudocholinesterase deficiency, secondary to a muscle biopsy H&P reveals hypertension, CAD, and hyperlipidemia

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Concerns Craniotomies often involve: Remifentanil, Propofol, and 0.5 MAC of volatile agent Succinylcholine for induction, no long term paralytics Antihypertensives on emergence, sometimes including Esmolol Succinylcholine is contraindicated, but can we still use Remifentanil and Esmolol?

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Succinylcholine First used in 1951 Chemically similar to 2 Acetylcholine (Ach) molecules Depolarizing neuromuscular blockade A competitive antagonist of Ach Short term paralysis, limited by pseudocholinesterase metabolism

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Pseudocholinesterase inhibitors Onset of symptoms usually occurs when 75% suppression of the wild type is present Can occur with as little as 50% depression, depending on comorbidities and coexisting conditions